“because a vast majority of programs that tie payment to cost and quality goals aren’t focused on disadvantaged populations, they create incentives for hospitals to avoid patients from these groups.
For example, in the 1990s, the New York State Department of Health began grading surgeons who performed coronary bypass surgery and making their report cards available to the general public. The aim was to make outcomes more transparent and to help surgeons improve. But to this day, the initiative makes it harder for Black patients to get surgery. Why? Because statistically, outcomes are generally worse for Black patients because of larger issues of systemic racism. So surgeons avoid them to protect their scores.
[..] There are also so-called value-based payment reforms, under which physician groups and hospitals get bonuses if patients use less health care overall but still improve their health. If a patient is hospitalized too many times or fails to get blood pressure under control, the physician group or hospital must pay a penalty — kind of like a fine. These reforms have been adopted by Medicare (because the Affordable Care Act required it) and private insurers. They have rapidly become more popular over the past decade.
While this does have its benefits, it also means that sicker patients who need more care or those who face other challenges, like not having a caregiver at home, become economically unattractive to hospitals. That’s why fewer value-based initiatives have been taken up in communities that are home to more people of color or are worse off economically. And where such initiatives are offered, patients who belong to minority populations are more likely to be shunned at the expense of better-off white ones whom doctors see as likely to have better outcomes.
[..] A value-based payment reform model seems as innocent as a daisy and worlds apart from the most overt forms of structural racism, such as segregated transportation or drinking fountains. Yet, far too often, such models share the consequence of systematically disadvantaging some groups, whether as a result of the design of policies or culturally ingrained behavioral patterns.
So what can be done?
First, an explicit and integral goal of all payment reforms adopted by public and private health insurers should be to reduce racial disparities in patient health outcomes. When payment is tied to the achievement of pre-defined goals, those goals should include making health care better for disadvantaged populations and more fair overall.
Second, all payment reform programs should be subject to disparate-impact monitoring. Chiefly, this entails the insurers, including the federal and state governments, measuring and documenting the extent to which access to care of structurally disadvantaged populations is affected. This should include expedited reporting and data collection to “sense” changes in health care access and quality for minority populations more rapidly.
Third, we need a complete and detailed picture of the full extent to which payment reforms are conduits, or barriers, in reducing health disparities and structural racism. Building on related work by the National Academy of Medicine and the Office of the Assistant Secretary for Planning and Evaluation, similar groups should inventory the current landscape and make concrete recommendations for action.”
Full article, Navathe AS and Schmidt H. New York Times, 2020.10.6